Khan tomó el volante de su amigo e hizo círculos en la arena, conduciendo por un sendero a lo largo del Red River, en Texas.

“Tan pronto como moví el cuerpo hacia un lado, se inclinó y volcó”, recordó Khan. El vehículo cayó sobre su brazo izquierdo.

“En mi antebrazo se me abrió una brecha de carne viva de unas 6 pulgadas”, dijo. “Podía ver el músculo. Podía ver la grasa. Podía ver la piel. La sangre se acumulaba”.

Al sentirse mareado, Khan se ató la chaqueta alrededor del brazo como un torniquete. Él y su amigo se las arreglaron para enderezar el todoterreno, manejar de regreso hacia la carretera y llamar al 911.

Cuando una ambulancia lo llevó a la sala de emergencias de en Wichita Falls, Khan se sorprendió al escuchar a un médico murmurar que se trataba de la peor herida en un brazo que había visto en su vida.

Khan necesitaba transporte urgente en a un centro de trauma en Forth Worth, para ser operado si quería tener alguna esperanza de salvar el brazo.

Mareado por los analgésicos, Khan se las arregló para preguntar a los médicos cuánto costaría el vuelo y si estaría cubierto por su aseguradora. “Creo que le dijeron a mi amigo: 鈥楾iene que dejar de hacer preguntas. Necesita subir a ese helicóptero. No se da cuenta de lo grave que es esta lesión”, recordó Khan.

Khan voló 108 millas hasta el en Fort Worth, el centro de trauma de Nivel I más cercano. Allí lo llevaron al quirófano para limpiar la herida, reparar sus huesos destrozados y hacer que la sangre fluyera hacia el tejido.

Se sometió a ocho operaciones para tratar de salvar el antebrazo izquierdo. Hasta que se rindió. Después de semanas en el hospital, les pidió a los médicos que le amputaran el brazo para poder seguir con su vida.

Y entonces llegó la cuenta.

Paciente:听Naveed Khan, de 35 años, radiólogo, casado y padre de tres hijos pequeños en Southlake, Texas.

Factura total: $56,603 por un vuelo en ambulancia. Después de negarse al principio, Blue Cross Blue Shield of Texas, la aseguradora de Khan, pagó $11,972. La compañía de evacuación médica le facturó a Khan los $44,631 restantes.

Proveedor de servicios:听Air Evac Lifeteam, una compañía de ambulancia aérea que opera 130 bases en 15 estados. Es propiedad de , un grupo que posee otras cuatro compañías de ambulancia aérea y una de ambulancia terrestre. Air Medical, a su vez, es propiedad de la gigantesca firma de capital privado , o KKR.

Servicio médico:听Khan fue trasladado en helicóptero desde United Regional Health Care System en Wichita Falls, Texas, al John Peter Smith Hospital (JPS) en Fort Worth.

El transporte rápido al centro de trauma era absolutamente esencial ya que se había cortado el flujo de sangre al brazo de Khan, dijo el doctor , director médico de servicios de trauma en el Hospital JPS.

“Si no hay sangre, significa que no hay oxígeno”, explicó Gandhi. “Si no hay oxígeno, significa que esas células van a morir”. Los minutos son preciosos y el helicóptero puede llegar de Wichita Falls a Fort Worth en una hora o menos, la mitad del tiempo que toma en ambulancia terrestre, agregó.

Las quejas sobre las elevadas facturas por servicios de ambulancia aérea son comunes. Las compañías encargadas de estos servicios defienden sus cargos.

, presidente de la (AAMS), dijo que las ambulancias aéreas requieren una tripulación más altamente capacitada que una ambulancia terrestre, porque sólo los pacientes más enfermos o con lesiones más graves necesitan transporte aéreo.

La AAMS para determinar el costo real de un vuelo de evacuación médica. El informe encontró que se necesitan alrededor de $2,9 millones al año para operar una sola base de helicópteros. Cada base ejecuta alrededor de 300 transportes al año, y los viajes cuestan alrededor de $11,000 cada uno, según el informe.

Una portavoz de Air Evac Lifeteam dijo que la compañía le cobra mucho a la gente porque está tratando de compensar lo que, según ella, son pagos exiguos de Medicare y Medicaid.

“Nuestro costo real por vuelo es de $10,200 más el costo no reembolsado en cada vuelo para Medicare, Medicaid y pacientes sin cobertura”, escribió Shelly Schneider, vocera de la compañía.

Los Centros de Servicios de Medicare y Medicaid (CMS) comunicaron que pagan un promedio de $4,624 por viaje, más $31.67 por milla, lo que resulta en un reembolso promedio de Medicare de $6,556 por ambulancias en helicóptero para adultos mayores. Medicaid en la mayoría de los estados paga menos.

La industria ha estado abogando arduamente para que Medicare aumente sus reembolsos, dijo Sherlock.听 tanto en la Cámara como en el Senado lo haría, pero no ha habido mucho movimiento con esos proyectos de ley.

Otros dicen que las estimaciones de costos de la industria están infladas por la expansión de una industria lucrativa. Demasiadas ambulancias aéreas permanecen inactivas la mayor parte del tiempo, señaló el doctor , profesor de medicina de emergencia de la Universidad de Chicago y director médico de la Red Aeromédica de la universidad.

Blumen dijo que la industria se expandió dramáticamente la última vez que Medicare aumentó sus pagos, en 2002. Y ahora hay 鈥�908, según cifras del año pasado鈥攍uchando por los pacientes y los beneficios al mismo tiempo.

Un portavoz de BCBS of Texas dijo que la aseguradora tiene una tarifa contratada con una compañía de ambulancia aérea dentro de la red, pero no es Air Evac Lifeteam. Después de negarse inicialmente a pagar por un reclamo fuera de la red, aceptó el pago de $11,972.

Pero en cierto sentido, la razón por la que las compañías de ambulancias cobran tanto es simplemente porque pueden hacerlo: Las ambulancias aéreas están reguladas en gran medida, no como atención sanitaria, sino como parte de la industria de la aviación. Las leyes federales impiden que los estados limiten las tarifas, rutas y servicios de aviación.

搁别蝉辞濒耻肠颈ó苍:听Khan ha permitido que Air Evac Lifeteam negocie con BCBS of Texas sobre la factura restante de $44,000 de la ambulancia aérea. La compañía le ha pedido que apele al Departamento de Seguros del estado, y aunque primero se opuso a la sugerencia, ahora está considerando hacerlo. Khan dice que no entiende por qué el vuelo en helicóptero, parte integral de la atención médica de emergencia que recibió, se trata de manera diferente a sus cirugías, cuidados de enfermería y fisioterapia.

惭辞谤补濒别箩补:听La mayoría de las personas con problemas de salud lo suficientemente serios como para requerir un vuelo en helicóptero no están en posición de preguntar si la compañía de evacuación médica está dentro de la red o si existe la posibilidad de elegir. Pero si usted o un miembro de su familia tiene tiempo para preguntar, podría valer la pena.

Los pasos que usted debe tomar si se enfrenta a una gran factura por un viaje de evacuación médica:

• Primero, deje que el proceso de su aseguradora se lleve a cabo. Blue Cross Blue Shield of Texas negó, al principio, el reclamo de Khan. Pero examinó detenidamente su póliza y vio que la amenaza de pérdida de extremidades estaba explícitamente cubierta. Apeló, y fue entonces cuando la aseguradora pagó 11.972 dólares.
• Segundo, 隆negociar! La compañía de ambulancia aérea podría estar dispuesta a negociar un acuerdo por una fracción de la factura para evitar recurrir a los cobradores de deudas, quienes les pagarían centavos por dólar.

Bill of the Month (La cuenta del mes) es una serie de investigaciones conjuntas de Kaiser Health News y NPR que analiza y explica cuentas médicas. 驴Tienes una factura de salud interesante que quieras compartir con nosotros? 隆颁耻é苍迟补苍辞蝉!

听

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Khan took the wheel from his friend and drove circles in the sand, on a trail along the Red River in Texas.

“As soon as I turned to the side where my body weight was, this two-seater vehicle 鈥� just tilted toward the side and toppled,” Khan recalled. It landed on his left arm.

“I had about a 6-inch-wide exposed flesh gap that I could see below, on my forearm,” he said. “And I could see muscle. I could see the fat. I could see the skin. The blood was pooling around it.”

Khan, feeling lightheaded, tied his jacket around his arm like a tourniquet. He and his friend managed to right the ATV, drive back toward the street and call 911.

When an ambulance delivered him to the emergency room at in Wichita Falls, Khan was surprised to hear a doctor murmur that it was the worst arm injury he’d ever seen.

Khan needed immediate transport to a trauma center for surgery in Fort Worth, if there was any hope of saving the arm.

Groggy from painkillers, Khan managed to ask the doctors how much the flight would cost and whether it would be covered by his insurer. “I think they told my friend, 鈥楬e needs to stop asking questions. He needs to get on that helicopter. He doesn’t realize how serious this injury is,'” Khan recalled.

Flown 108 miles to in Fort Worth, the closest Level I trauma center, Khan was whisked into surgery to clean out the wound, repair his shattered bones and get blood flowing to the tissue.

He had a total of eight operations to try to save his left forearm before he finally gave up. After weeks in the hospital, he asked the doctors to amputate, so he could get on with his life.

And then the bill came.

Patient: Naveed Khan, 35, a radiologist and married father of three small children in Southlake, Texas.

Total Bill: $56,603 for an air ambulance flight. Blue Cross Blue Shield of Texas, Khan’s insurer, paid $11,972, after initially refusing altogether; the medevac company billed Khan for the remaining $44,631.

Service Provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It’s owned by a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm , or KKR.

Medical Service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.

What Gives: Khan got his first call from just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would likely cost more than $50,000 and asked him how he planned to pay.

For Khan, rapid transportation to the trauma center was absolutely essential since the blood supply to his arm had been cut off, said , the medical director for trauma services at JPS Hospital.

“If there’s no blood going that means there’s no oxygen,” he said. “It there’s no oxygen, that means those cells are going to die.” Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.

But complaints about sky-high bills to patients for air ambulance services are common. Since launching the “Bill of the Month” series in February, NPR and Kaiser Health News have received more than a dozen bills from critically ill patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers’ payments.

Air ambulance companies defend their charges.

, president of the , a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.

AAMS to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.

A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.

“Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage,” wrote Shelly Schneider, the company spokeswoman.

The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile 鈥� which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.

The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. in both the House and Senate would do so, but there hasn’t been much movement on those bills.

Others say the industry’s cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.

Too many air ambulances sit idle much of the time, said , a professor of emergency medicine at the University of Chicago and medical director of the university’s Aeromedical Network.

Blumen said the industry 鈥� which is dominated by a few companies owned by private equity firms 鈥� expanded dramatically the last time Medicare boosted its payments, in 2002. And now there are 鈥� 908 as of last year 鈥� fighting for patients and profits at the same time.

“The number of helicopters is outrageous for the continental United States,” he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.

A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.

But in some sense, the reason ambulance companies charge so much is simply because they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.

So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would set up a council of industry experts to address balance billing and other issues, and set up a complaint line for consumers.

Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000 air ambulance bill. The company has asked him to appeal to the state’s Department of Insurance, and though he first balked at the suggestion, he’s now considering doing so. Khan says he doesn’t understand why the helicopter flight, an integral part of the emergency medical care he received, is treated differently than his surgeries, nursing care and physical therapy.

“I thought that this was another piece of that puzzle,” he said. “It turns out that this was glaringly different.”

He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration: “How do I hold him while he’s crying and at the same time heat up his bottle?”

Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, is frustrated to learn that the air ambulance company expects him to pay far more than the actual cost of his flight.

“It’s unfair,” he said. “It’s random, it’s arbitrary. It’s whatever price they want to set. And to put that onto a person who’s already been through what I’ve been through, I hate to say it, but it’s cruel.”

The Takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask if the medevac company is in-network or whether there’s a choice. But if you or a family member has time to ask, it could pay off.

Steps you should take if you’re faced with a huge bill for a medevac ride:

• First, let your insurer’s process play out. Blue Cross Blue Shield of Texas first denied Khan’s claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that’s when the insurer paid $11,972.
• Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.

Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.

Many air ambulance companies offer membership plans that can cost less than $100 a year, and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When someone needs an air ambulance, they are often not in a position to choose which company will respond to the call.

Bill of the Month is a crowdsourced investigation by听Kaiser Health News听and听 that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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In October, he finally made an appointment to see his doctor about it. “It wasn’t severe,” he said. “It was just kind of bothersome. It just kind of annoyed me during the day.”

The internist, Dr. John Ardesia, checked him out and referred him for a CT scan at a nearby imaging center. The radiologist didn’t see anything wrong on the images, and Ardesia didn’t recommend any treatment.

A few weeks later, Hynden, who has a high-deductible health insurance policy with Cigna, . He paid it and moved on.

But three months later, in mid-January, Hynden was still feeling lousy. He called up Ardesia’s office again. This time, the doctor wasn’t available. A nurse practitioner, concerned that Hynden might be suffering from appendicitis, advised him to go to the hospital right away.

“I was a little worried,” Hynden recalled. “When he told me to go to the ER, I felt compelled to take his advice.”

Hynden arrived later that morning at Gulf Coast Medical Center, one of several hospitals owned by Lee Health in the Fort Myers area. The triage nurse told him the problem wasn’t his appendix, but she suggested he stick around for some additional tests 鈥� including another CT scan 鈥� just to be safe.

“It was the exact same machine. It was the exact same test,” Hynden said.

The results were also the same as the October scan: Hynden was sent home without a definitive diagnosis.

And then the bill came.

Patient:听Benjamin Hynden, 29, a financial adviser in Fort Myers, Fla.

Total Bill:听$10,174.75, including $8,897 for a CT scan of the abdomen

Service Provider:听Gulf Coast Medical Center, owned by Lee Health, the dominant health care system in southwest Florida

(Story continues below.)

Medical Procedure:听A computed tomography scan, commonly known as a CT or CAT scan, uses X-rays to create cross-sectional images of the body. Hynden got his October scan at Summerlin Imaging Center, a standalone facility in Fort Myers that offers a range of diagnostic tests, including X-rays, MRI and CT scans.

Rick Davis, co-owner of Summerlin, said his center is small and independent, so he doesn’t have much bargaining power. That means insurance companies pretty much dictate what he can charge for a scan. In Hynden’s case that was , including the cost of a radiologist to read the images.

Ultimately, what Medicare decides to pay for a scan sets the standard. “The Medicare fee schedule is what all the other companies use as their guideline,” Davis said. “It’s basically the bible. It’s what everyone goes by.”

Summerlin’s office manager, Kimberly Papiska, said that the maximum the center ever bills for a CT scan is $1,200, but that the rates insurance companies pay are usually less than $300.

Hynden was shocked when he got the second CT scan in January, and the listed price was $8,897 鈥� 33 times what he paid for the first test.

Gulf Coast Medical Center is part of his Cigna insurance plan’s approved network of providers. But even with Cigna’s negotiated discount, Hynden was on the hook for $3,394.49 for the scan. The additional ER costs added another $261.76 to that bill.

What Gives:听We called Gulf Coast Medical Center and its parent company, Lee Health, to understand why they billed nearly $9,000 for a single test. No one at the health center or hospital would agree to an interview.

Lee Health spokeswoman Mary Briggs responded with an emailed statement: “Generally that it is not unusual for the cost of providing a CT scan in an emergency department to be higher than in an imaging center. Emergency department charges reflect the high cost of maintaining the staffing, medical expertise, equipment, and infrastructure, on a 24/7-basis, necessary for any possible health care need 鈥� from a minor injury to a gunshot wound or heart attack to a mass casualty event.”

Do the hospital’s costs and preparations justify a list price that’s so much higher than the nearby imaging center’s tab? We asked some experts in medical billing and management for their thoughts.

Emergency rooms often charge people with insurance a lot of money to make up for the free care they provide to uninsured patients, said Bunny Ellerin, director of the Healthcare and Pharmaceutical Management program at Columbia Business School in New York. “Often those people are what they call in the lingo 鈥榝requent flyers,'” Ellerin said. “They come back over and over again.”

She said hospitals also try to get as much money as they can out of private insurance companies to offset lower reimbursements from Medicare and Medicaid.

Even in that context, the price of Hynden’s CT scan was off the charts.

Healthcare Bluebook, a health care pricing tool, says with contrast, like Hynden had, in Fort Myers is between $477 and about $3,700. It pegs a fair price at $595.

The higher price from Gulf Coast Medical Center and its parent company could be a result of their enormous pricing power in Fort Myers, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University.

Lee Health owns the four major hospitals in the Fort Myers area, as well as a children’s hospital and a rehabilitation hospital, according to its website. It also owns several physician practices in the area. When you drive around Fort Myers, the blue-green Lee Health logo appears on buildings everywhere.

“Anybody who’s in Fort Myers is going to want to get care at these hospitals. So by having a dominant position, they have great bargaining power,” Anderson said. “So they can raise their rates, and they still do OK.”

Anderson said his research shows hospital consolidation has been driving prices higher and higher in recent years. And because more and more people, like Hynden,听, they’re more likely to be on the hook for huge bills.

So Lee Health and other dominant hospital systems mark up most of their services on their master price lists 鈥� the list that prices a CT scan at Lee Health at $8,897. Anderson calls those lists “fairy-tale prices” because almost no one actually pays them.

“Everybody who’s taken a look at it agrees 鈥� including the CFO of the organization 鈥� that it’s a fairy-tale thing, but it does have relevance,” Anderson said.

The relevance is that insurance companies typically negotiate what they’ll pay at discounted rates from list prices.

So from the master price of $8,897, Cigna negotiated Hynden’s bill down to $5,516.14 鈥� a discount of almost 40 percent. Then Cigna paid $2,864.08, leaving Hynden to pay the rest.

“If it wasn’t for that听CT scan, I don’t think this whole thing would have been so difficult and so blatantly obvious that they’re extremely overcharging for that service,” Hynden said.

Resolution:听Hynden never got a definitive diagnosis from the CT scans. Several weeks after his second test, however, he went to a nearby urgent care center, also run by Lee Health, and underwent an ultrasound on his abdomen. That test, which cost about $175,听revealed some benign cysts that he said his doctor said are likely to go away on their own.

The Takeaway:听Tests and services are almost always going to be more expensive in an emergency room or hospital setting. If your doctor suggests you go to an ER, it might be worth asking whether an urgent care or walk-in clinic would suffice.

Sources:听Explanations of Benefits provided by Benjamin Hynden and interviews.

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Now that they’re in charge, the bill they’ve released as an alternative (the ) would effectively eliminate the requirement to buy coverage and might听open up more health care choices.听It’s also听under fire because it may cause millions of people to lose their coverage. According to the nonpartisan Congressional Budget Office, more people could be without insurance by 2026 if it passes.

Many questions came in about the elimination of the requirement to buy insurance, known as “the mandate,” and how the lack of one might affect听the health insurance market.

Is the mandate in the GOP bill? It won’t work if people sign up only when they are sick.

.@sjp3121 I read mandate still there, just no fine. Is this accurate? Won't work without mandate if only sign up when sick.

鈥� ILBarb鈽笍 (@BarbinIL52)

Kodjak: The mandate is technically still written into the law, but since no one will enforce it under this new bill, it’s unlikely to have any impact. In fact, the Internal Revenue Service has already issued that suggests it may not enforce the mandate very actively even now, before this bill becomes law. The result? People who think insurance is too expensive and don’t expect to need it are unlikely to sign up for a health plan.

Rovner: It’s true that the GOP bill technically preserves the mandate, but it eliminates the penalties. Instead, the bill would require those with a lapse in insurance of more than 63 days to pay an insurance premium that’s 30 percent higher for one year. Analysts say that could actually serve as a disincentive for healthy people to purchase insurance if they’ve had a break.

Can someone wait until they are sick to buy insurance, knowing that they would have to pay a 30 percent fine?

Rovner: Not exactly. There will still be standardized open enrollment periods once a year, and you will only be able to buy insurance outside of those windows if you have a life change, like moving or losing a job. But if you’re willing to wait as long as 11 months, then, yes, you can wait and buy insurance after you get sick.

Kodjak: It’s not without risk. The Department of Health and Human Services has already proposed regulations that would reduce that to six weeks from the current three months. So a patient may incur some health care costs while awaiting the open enrollment, and then face the 30 percent penalty when they do buy a health plan. However, if the individual has a health issue where treatment can wait, then they certainly can enroll at the correct time and then seek medical care.

We also got a lot of questions about the GOP bill’s new tax credits to help people buy insurance, and how different they would be from the structure of purchasing help in the ACA.

Explain the difference between tax credits and subsidies, and will tax credits be distributed quarterly or at the end of the year?

Kodjak: Both the ACA and the AHCA use advanceable, refundable tax credits. That means the government each month sends the tax credit amount to your insurance company.

We refer to the Obamacare financial assistance as a “subsidy” in part because the amount fluctuates and is based on your income 鈥� the idea is to limit your health costs to a specific percentage of your income. In addition, under the ACA, there are payments to insurers to help cover the copayments and deductibles of lower-income people.

Rovner: The tax credits differ in how large they are and how they are calculated. The ACA tax credits are based on income and how much insurance costs in a given area. The GOP credits, by contrast, are based primarily on age and do not vary according to the cost of insurance in an area, so in low-cost parts of the country they will go further than in very high-cost areas.

In addition, the ACA has a series of subsidies that help those with low incomes (under 250 percent of poverty; about $50,000 for a family of three) pay their deductibles and other out-of-pocket expenses in addition to the tax credits to help pay for premiums.

Why does the GOP bill provide age-based tax credits instead of income-based ones?

what's the policy behind providing age-based tax credits as opposed to income-based?

鈥� Mollie Gelburd (@molliegel)

Kodjak: The basis for age-based tax credits is that people who are younger tend to have fewer health costs, so insurance policies are likely to be lower-priced for them than for older people.

Republicans prefer the fixed credits in part because they are cheaper, and more predictable, than the income-based credits under the Affordable Care Act. That’s because those ACA credits rise as premiums rise, giving insurers little incentive to keep their premiums low. Republicans hope that by restraining the government’s financial help to patients, insurance companies will offer cheaper policies that better match the cost of the tax credits.

Rovner: Younger adults, on average, need less health care than older adults. The ACA limited the differential in premiums for older adults to three times more than the amount charged to younger adults. The GOP bill would change that so older adults could be charged five times more. The change would make insurance less expensive for younger people, likely enticing more of them to enroll, and lowering premiums for all, at least marginally, according to the . But it would dramatically increase premiums for older adults, particularly those aged 55-64, just under the age to qualify for Medicare.

Which brings us to this question, which represents several we received about how the AHCA appears to disproportionately penalize听people ages 55-64.

Do I face a penalty for waiting to buy health insurance until I’m eligible for Medicare in three years? I’m concerned that I’ll be stuck with an expensive plan.

If I'm 62 and I decide 5:1 health insurance is too expensive and I wait for Medicare, no penalty for me, right?

鈥� Anne Paulson (@KrampusSnail)

Kodjak: No 30 percent penalty if you wait for Medicare, but remember, if you get sick while you’re waiting, you could be in financial trouble.

Rovner: That is correct. Also, remember, if you fail to sign up for Medicare when you first become eligible at age 65, you would also pay . It’s 10 percent per year, forever.

Got more questions? We’ll keep answering them as the GOP bill moves through Congress. Send them to us via Twitter at #ACAchat or via email at KHNHelp@kff.org.

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